As neurosurgery evolves, more physicians are considering the pros and cons of subspecialty practice.
Subspecialization is a controversial topic that organized neurosurgery, and other medical specialties, has been debating for the greater part of the past decade. Should fellowship-trained neurosurgeons qualify to sit for Certificates of Added Qualifications under the American Board of Neurological Surgery? Should subspecialties that cross more than one currently recognized specialty, like Pain Medicine, be allowed to form their own boards, or issue joint specialty subcertificates? Or, should every neurosurgeon, equally trained in residency, receive the same specialty qualifications, regardless of whether an individual chooses to focus on a specific area of the field, therefore representing a single, united definition of “neurosurgeon” to patients, third-party payers and referring physicians?
The American Board of Medical Specialties
The American Board of Medical Specialties (ABMS) is made up of representatives from its 24 approved medical specialty boards, including the American Board of Neurological Surgery. The ABMS charges itself with the mission of maintaining and approving the quality of medical care by assisting member boards in their efforts to develop and utilize professional and educational standards for the evaluation and certification of physician specialists. Member boards must adhere to the standards set by the ABMS in relation to how certificates are awarded, and cannot change certification requirements without the consent of the ABMS. Each member board must have strict, written criteria for issuing board certification including residency requirements, case load requirements, written and oral exams and more. One of the reasons the ABMS was initially created in 1933, was to standardize the definition, training and certification of medical specialists.
The ABMS also establishes standards for the approval of new specialties and subspecialties. In order for a new board to join the ABMS, it must receive approval by both the ABMS and the American Medical Association’s Council on Medical Education (AMA/ CME). The process begins with an official application to the Liaison Committee for Specialty Boards, an organization sponsored by the ABMS and the AMA/CME. Six of the 24 members have been approved since 1949, and the last medical specialty board approved was the American Board of Medical Genetics in 1991.
Once a board is approved as a member of the ABMS, it can issue both primary certification certificates and subspecialty certificates. Currently, the 24 member boards issue certificates in 37 areas of general specialization and certificates of special or added qualifications in 75 areas.
The American Board of Neurological Surgery
The American Board of Neurological Surgery (ABNS) is the recognized ABMS board for neurosurgery. There are 14 directors in the ABNS that represent the following organizations: The American Association of Neurological Surgeons (4); Society of Neurological Surgeons (3); American Medical Association (2); Congress of Neurological Surgeons (2); American Academy of Neurological Surgeons (1); American College of Surgeons (1); and Neurosurgical Society of America (1). Upon successful completion of both the written and oral board exams, applicants are rewarded with specialty certification in neurological surgery. The ABNS does not currently recognize or issue any subspecialty certificates.
Non-ABMS Recognized Boards
Occasionally, a group of physicians create a separate board that is not officially recognized by the ABMS. These types of boards include the American Board of Pediatric Neurosurgery, American Board of Pain Medicine and American Board of Spine Surgery. These boards set their own standards and criteria for certification, and are completely independent, self-designated boards. Certification from these boards is usually not recognized by third-party payers, hospital review committees or the medical community.
“Although some of these boards incorporate testing measures and review of training, they have not demonstrated the program review and quality control integral to the process of the ABMS,” said Sidney L. Tolchin, MD, 1995-96 AANS President, in Neurosurgical Focus. “Self-designation can be accomplished, therefore, by listing oneself as such on a name plate, placard or by advertising in a medium such as the Yellow Pages.”
However, the concept of only recognizing ABMS boards has recently been challenged as self-designated boards upgrade and establish strict criteria for certification. The American Board of Pain Medicine recently achieved “ABMS equivalent” status in the state of California.
“I consider myself double-boarded – both by the American Board of Neurological Surgery and the American Board of Pain Medicine,” said Kim Burchiel, MD, former President of the American Board of Pain Medicine.
The American Board of Pain Medicine is made up of pain specialists from neurosurgery, neurology, anesthesiology, and other specialties. The group has officially applied to the ABMS for official recognition, but has not yet received a response.
Levels of Subspecialization
Official recognition of subspecialization can be accomplished at various levels. The highest level is the creation of a separate board for the specialty. A board may offer different primary certificates as a way of distinguishing members with varying backgrounds and interests. These candidates take different initial written and oral board examinations. For example, the American Board of Radiology allows its applicants to choose between four different general certificates: Diagnostic Radiology, Radiation Oncology, Radiological Physics or Radiology.
A board also may offer subcertificates in a specific area. In order to obtain a subcertificate, the applicant must first pass the primary exam in that specialty. There are additional criteria an applicant must meet in order to sit for a subcertificate exam, which in most cases involves additional, officially approved training. For example, radiology offers four subcertificate areas in addition to the nine primary certificates; the American Board of Anesthesiology offers subspecialty certificates in critical care medicine and pain management; and the American Board of Otolaryngology offers subspecialty certificates in otology/ neurotology and pediatric otolaryngology. Some of the larger boards, including Internal Medicine, offer up to 10 different subcertificates.
Different boards may also issue joint subcertificates with other boards. In this case, applicants would first pass their respective board’s general exam and then meet the additional criteria to sit for certification. For example, the American Board of Orthopaedic Surgery, American Board of Plastic and Reconstructive Surgery, and the American Board of Surgery jointly sponsor a subspecialty certificate in hand surgery. Likewise, the sports medicine subcertificate is jointly sponsored by the boards of Family Medicine, Internal Medicine, Emergency Medicine and Pediatrics.
Most Certificates of Added Qualifications are granted after formal post residency training in the form of an Accreditation Council for Graduate Medical Education (ACGME) approved fellowship. The ACGME is made up of the American Medical Association, Association of American Medical Colleges, American Hospital Association, Council of Medical Specialty Societies, and the ABMS. The ACGME works with each ABMS approved board to set up Residency Review Committees (RRC) in each specialty area. RRCs set and monitor the criteria and quality of both residency programs and approved fellowship programs.
“Currently in neurosurgery, there are no ACGME approved fellowships,” said Julian Hoff, MD, Chairman of the AANS/CNS Fellowship Task Force. “There is a lot of inconsistency in the duration and quality of neurosurgery fellowships right now. One of the recommendations of the Task Force is to change this and formalize the fellowship process in neurosurgery.”
The AANS/CNS Sections have been charged with developing fellowship criteria for their respective areas. Pediatric neurosurgery fellowships are currently accredited through the Accreditation Council for Pediatric Neurosurgery Fellowships (ACPNF).
“Pediatric neurosurgeons were concerned with the lack of quality in their educational experience and, therefore, created a mechanism to inspect and establish fellowship guidelines and monitor programs for content and quality,” said Marion L. Walker, MD, Chairman of the AANS/CNS Section on Pediatric Neurological Surgery.
“The ACPNF accreditation process is rigorous and mirrors the parameters set forth by the RRC. It is our hope that one day, councils like the ACPNF will cease to exist and that accredited subspecialty training will fall under the auspices of the ABNS.”
Subspecialization Within Neurosurgery
As medicine evolves and technology progresses, the question of subspecialization within neurosurgery is coming to a head. Should subcertificates be offered, or should the integrity of the general neurosurgeon be supported?
“Subspecialization within neurosurgery is nothing new. It is about time we recognized these doctors for their additional training,” Dr. Walker said. “Subcertification is a simple way to provide neurosurgeons with the appropriate recognition for their current and focused expertise, support continuing medical education and provide the quality of care our patients deserve and demand.”
Presently, the ABNS is discussing four possible options for addressing subspecialization within neurosurgery: 1) Make no changes; 2) maintain accreditation/ credentialing as is, but formalize the various subspecialties’ role in the ABNS (ie: examiners, guest examiners, exam questions, etc.); 3) accredit neurosurgery fellowships through the ACGME, but do not offer subcertificates; or 4) accredit and offer subcertificates.
Accrediting neurosurgical fellowships through the ACGME is not an easy task. ACGME requires that there be at least 25 potential programs in the area and the board must issue statements on the impact the fellowship will have on the core curriculum in the specialty, among other criteria. According to ACGME, fellows involved in an approved program cannot be paid for their work. This, combined with the fact that the grace period for federally issued student loans does not extend into fellowships, puts great financial strain on both the program and the fellow. There are several categories in other specialties where ACGME approval has been awarded, but no fellowship program has applied.
“Fellowship material is not supposed to be a significant part of the core curriculum for that specialty,” Don Quest, MD, ABNS Secretary, said. “If we grant spine fellowships, we are saying that spine is not a significant part of the core curriculum for neurosurgical residents. The proposal also must be reviewed and approved by the entire ABMS, including our competition. We want to help neurosurgeons, not open ourselves up to infringement by orthopedic surgeons.”
Another proposal being considered is to accredit neurosurgical fellowship programs through the Society of Neurological Surgeons, which is comprised of program directors.
“This concept may allow us to recognize neurosurgeons who did additional training, but keep it in house where we have better control,” Martin H. Weiss, MD, President of the AANS, said.
If the ABNS decides to issue subcertificates, then they must go through the ABMS subcertificate process, which includes comment from other organizations. For example, when the American Board of Otolaryngology proposed its neurotology subcertificate, the ABNS had considerable comment and was successful in altering what procedures would be included for this subcertificate.
Over the past decade, there have been several debates between specialties that have led to joint subcertificates or the denial of subcertificates, including battles between plastic surgery and otolaryngology for reconstructive facial surgery (see page 11 for the highlights of this struggle).
“Our experience in plastic surgery has been, whether you like it or not, in areas where there is direct competition from other specialties. You have to offer a subcertificate or be prepared to lose that area completely,” said Kenna Givens, MD, Chairman of the American Board of Plastic Surgery. “We did not necessarily want to offer subcertificates, but felt it was in the best interest of our specialty.”
Is Subspecialization the Trend?
Is subspecialization the answer to protecting the public against unqualified practitioners, improving patient care, enhancing translational research and advancing the specialty of neurosurgery? Many would say, “Yes,” arguing that healthcare trends toward centers of excellence, reduced length of stay and overall hospital cost emphasize the need for subspecialization.
Others, however, including some managed care organizations that operate with one neurosurgeon for every 50,000 enrollees, believe that the future of medicine rests in the hands of the generalist. They caution against the fragmentation of medical services that results from overspecialization, and argue that the all-purpose, do-everything generalist is more marketable to third-party payers.
With all that is happening in today’s fast-changing healthcare environment, the debate surrounding subspecialization will continue to be a source of controversy for years to come.
Yes!Subspecialization: The Inevitable Road We Must Travel We are neurosurgeons because our predecessors chose to develop neurological surgery as a specialty of general surgery. The question before us now is whether further specialization in our field will promote progress and development in neurological surgery, or simply fragment an already small discipline into a series of segmented, “special interest” groups.
KIM J. BURCHIEL, MD I am of the opinion that advancement in our specialty can only be fostered by a concentration of intellectual and creative effort in each of the discrete subspecialties that compromise our field. The trick will be to advance the interests and practice of these subspecialties, while at the same time maintaining the fundamental integrity of neurosurgery as a whole. Neurosurgery is already very specialized. The average neurosurgeon has a broad range of competencies, including many, if not most, surgery. Unfortunately, this degree of specialization has come at the cost of other disciplines previously occupied by neurosurgery, such as peripheral nerve surgery, peripheral vascular surgery (i.e. carotid endarterectomy), and pain surgery. We need to broaden our “specialized” practices to re-incorporate these areas into the practice of neurological surgery. Broadening the Neurosurgical Horizon In my opinion, any perception of an “oversupply” of neurosurgeons is based on an unnecessarily limited definition of neurological surgery. Expanding the horizons of neurological surgery will expand the number of neurosurgeons needed. Competition within neurosurgery is largely based on overlapping, and in some cases, identical clinical experience of the competing practices. Specialization of practices may well promote collegial cooperation and cross-practice referral. Furthermore, as a training program director, I am confident that neurological surgery is simply too broad a discipline for every trainee to become competent in every aspect of our specialty. There is simply not enough training time available to comprehensively train every resident in every subdiscipline. To that end, subspecialization may provide our future neurosurgical leaders with an opportunity to expand their clinical and academic skills, as well as provide them with a mechanism to promote scientific advancement within the field of neurosurgery. Establishing Formal Training Guidelines Neurosurgery, as a core discipline, can survive and thrive by emphasizing a core curriculum during training, such that fundamental knowledge and skills are imparted in every training program. This core curriculum is already under development by the Society for Neurological Surgeons and by The American Association of Neurological Surgeons and Congress of Neurological Surgeons through their Sections. By necessity, the curriculum will be constrained by the five-year training period now accredited by the Resident’s Review Committee. Subspecialty training should be reserved for fellowships, broadly defined as a period of postgraduate training of several months to years devoted to one of the component subspecialties of neurological surgery. Benefits of Subspecialization We can anticipate both immediate and future benefits to neurological surgery, and to society at large, by further subspecialization in our practices:
There is no doubt in my mind that if we allow neurosurgery to fragment into separate component disciplines, we will lose our identity in organized medicine, and cease to be recognized by a public to whom neurosurgery is synonymous with superlative clinical medicine. The problem is that without subspecialization, neurosurgery as a specialty will certainly stagnate both clinically and scientifically. The prospect is surely too dismal to contemplate, particularly as we enter a new millennium that will see a continued acceleration in the growth of our understanding of basic neuroscience and the function of the human nervous system. Further subspecialization will continue to occur in neurosurgery, with or without the various regulatory bodies of our discipline. The challenge to us is not how to limit subspecialization, but how to maintain the connections that tie us together as a specialty. Kim Burchiel, MD, is Chairman of the Department of Neurological Surgery at Oregon Health Sciences University. A 14-year member of the AANS, Dr. Burchiel is the Secretary/Treasurer of the AANS/CNS Section on Pain and a former President of the American Board of Pain Medicine. |
No!Subspecialization – At What Cost? The first disadvantage of subspecialization is the threat of fragmentation within our specialty. Neurosurgeons really do need to stand together, because there are so few of us, and there are so many people who would like to move into the area of neurosurgery without having received the necessary training to do so. The fewer voices that we have to combat these threats, the more vulnerable we are to attack.
EDWARD R. LAWS JR., MD Excessive subspecialization also may lead to a loss of perspective, meaning that individuals who are devoted to a narrow window of the field may lose interest and their ability to contribute to organized neurosurgery as a whole. This, of course, is an intellectual disadvantage that we cannot afford. And, one would hope that neurosurgeons who decide early in their careers to concentrate on a particular aspect of the field might remain vitally interested in neurosurgery and clinical neuroscience in general. This loss of perspective can be translated into a loss of versatility, if individuals completely abandon segments of neurosurgical practice. In such cases, a superspecialized neurosurgeon may not function very well in a group when it comes to taking a call or handling an emergency. Once again, a certain amount of expertise and a broad knowledge base need to be maintained by us all. Impact of Subspecialization There certainly is an impact from subspecialization on the training of neurosurgical residents and fellows, and on the shaping of the neurosurgeon’s career. Because we see a perceived need to become an expert in a certain area and to obtain additional credentials, both for career building and in some instances to find a job, pressures exist that have led to an increased training period. There is a growing desire on the part of trainees for fellowship experiences following ordinary neurosurgical training, and for early decisions on the part of our residents, which may in some cases preclude a broad-based education and residency experience. One aspect of subspecialization that is apparent in some of our colleagues who do coronary bypass surgery is the phenomenon of boredom and burnout. Although everything we do involving the nervous system is exciting, if one works in too narrow of a field the risks of becoming humdrum and commonplace do exist. In individuals who are working extraordinarily hard in a very narrow area, the phenomenon of burnout can readily occur. Neurosurgery is a great profession and it should be for all of us. Part of the fun is the daily challenge of confronting difficult disorders affecting the nervous system. If subspecialization limits the experiences that produce so much in the way of professional rewards, then we need to look at the costs that we pay for a subspecialty career. Edward R. Laws Jr., MD, is Professor of Neurological Surgery and Medicine at the University of Virginia. A 24-year member of the AANS, Dr. Laws served as the 1997- 98 President of the AANS and is the current Chair of the AANS Nominating Committee. |